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Event Booking System
Team Portal
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Portfolio
Contact

Heartworm Treatment Release Form

Please note: this form is for demonstration purposes only, no pet care is available from this site.

All required fields are marked {*}

Client Information

Client Name:

First Last

Today's Date:

Month

Day

Year

Client Email:

Patient Name:

Color:

Sex:

Male

Female

Spayed/Neutered?

Yes

No

Age:

Breed:

I authorize the performance of the following procedure(s):

Is your pet currently on a special diet (including treats)?

Yes

No

If "Yes" above please explain:

Has your pet had any medications in the last 24 hours (including non-prescription medication or supplements)?

Yes

No

If "Yes" above please explain:

Included in the heartworm treatment package is: A complete physical exam, pre-treatment bloodwork, radiographs, immiticide injections (Based on the weight of the animal), steroid injection(s), and three days of boarding.

Do you need a refill on heartworm, flea, and tick prevention?

Yes

No

If "Yes" above which preventative do you need and how much would you like?

Please list any vaccinations your pet is currently due for: (If they are up to date please say None)

I Authorize

Do we have your authorization to bring them up to date on their shots?

• Did your pet having any coughing which required a steroid to treat?

Yes

No

If "Yes" above please explain

If your pet has received the first melarsomine injection, did they have any back pain that required medication?

Yes

No

I Understand and Accept

I understand that while the treatment used in this hospital is one of the safest used in veterinary medicine, NO treatment is without medical risks. No guarantee can be made legally or ethically to me on the outcome of any procedure performed. Any complications arising from the above procedure will charge for at time of recheck visit.

Name

First Last

Signature

Phone number where you can be reached TODAY (Very Important)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

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